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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> { Telephone (209) 466-6781 <br /> 0\ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address J400 City�,� Lot Size PM <br /> r /bhN3/ <br /> Owner's Name F h ress • Phone <br /> Gf/J� 'PFJ <br /> Contractor� /l�`.$ �Z',�,Address :?Z7_z9 1_6111_ -�License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PIMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE " TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout _I I Irrigation _Approx. Depth [ I Eastern Surface Seal Installed by _ <br /> Repair Work Done L] Type of Pump H,P. State Work DoneJyOa �/ � <br /> Well Destruction .�V Well Diameter Sealing Material (top 50') —T C� 6)Z,0_�� <br /> Depth �49f Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOk 12 REPAIR/ADDITION [ I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantt r I requitions. Complete drawing on reverse <br /> Signed X---��� '/" - r Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2--43 Area CrNb <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1111-2 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATEINFO CASH PERMIT*NO. <br /> cccc777� �-yr� <br /> a EH 13-24(REV.i i n 57 —Y4`T-1 _C � <br /> EH 14-26 • �l.J <br />